Project Summary Thanks to the success of HIV antiretroviral therapy (ART), persons living with HIV (PLWH) in the US are living longer, and aging. With this success comes the new challenge of meeting the increasing need for nursing home (NH) care. Caring for these patients is complex. Aging PLWH experience complications of HIV and ART, high rates of HIV-Associated Non-AIDS conditions such as liver and lung disease, and high rates mental health disorders. Most NH providers have little experience caring for persons with this combination of medical issues. Unfortunately, very little is known about NH care for PLWH, such as what facilities they are admitted to, the quality of the care they receive, and the outcomes of that care. Absent such information it will not be possible to prepare and train NH staff to effectively and efficiently care for the large numbers of aging PLWH who in the next decade will need their care. The long term goal of this research is to drive the development of efficient, high quality NH care for PLWH. The objective of this application, the first step toward this long term goal, is to assemble and analyze national, population based data about the quality of, and variations in, NH care for PLWH. The central hypothesis motivating this proposal is that there are disparities in NH care for PLWH. We hypothesize, first, that PLWHs are likely to be admitted to lower quality NHs (?between? NH effects), and, second, that they are likely to get poorer care than HIV negative (HIV-) patients in those NHs (?within? NH effects). These hypotheses are based on several observations, including that disparities in care have been consistently found for PLWH, that hospitalization rates for HIV in the ART era have fallen so most NHs have not needed to learn how to provide post-acute (i.e., post-hospital) care for PLWH, and that there are volume- outcome relationships have been previously demonstrated in HIV care. The rationale for this work is that it will provide an evidence base for interventions to improve the quality of NH care for PLWH. The sample for this project will include PLWH admitted to NHs in nine high HIV prevalence states between 2001 and 2012, including those with Medicaid, Medicare, and Dual Eligibles. We propose the following Specific Aims: 1) Compare indicators of overall quality of NHs that have low, medium, and high experience caring for PLWH. 2) Compare the quality of care experienced by Medicaid HIV+ and HIV- patients in low, medium, and high HIV experience NHs. 3) Identify education, training, and attitudinal factors related to HIV care that differentiate high and low experience and high and low quality NHs from each other. We will accomplish this through qualitative interviews with Directors of Nursing from NHs selected based on findings from Aims 1-2. This approach is innovative because we propose is new ways to understand disparities in NH care for PLWH. The approach is significant because population-based data about the quality of care in the post-acute care sector for patients with HIV is a necessary precondition for evidence based clinical and policy interventions aimed at achieving the triple aim of better care, better health, and lower cost.